Director Claims Management

🔥 13 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

⏰ Full Time

🔴 Lead

👔 Director

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Health Admins

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2015

💼 Consulting

🛡️ Insurance

📣 Marketing

Consulting • Insurance • Marketing

Health Admins is leading healthcare in a new direction by simplifying access to healthcare services and making them more affordable for members. Through their Smart Healthcare Platform, they provide TPA software, healthcare navigation, bill negotiation, and claims processing services. Their goal is to enhance member satisfaction and foster loyalty by offering powerful tools and personalized assistance to control costs and improve healthcare decisions.

📋 Description

• Own full accountability for the assigned claims operation, ensuring accurate and timely claims processing and developing strategies, staffing, and process improvements as volume grows • Run the two health share Needs teams, including intake, clinical review, processing, pay/deny/pend determinations, reimbursements, and runout • Meet and sustain client service level agreements and own SLA tracking and responses when standards are at risk • Build toward traditional medical claims administration for self-funded employer plans across intake, adjudication, repricing, payment, and runout • Lead Client Managers, Team Leads, and Coordinators across assigned teams • Own workload distribution, escalations, performance management, hiring, staffing plans, and staff development • Manage vendor relationships across clearinghouse, cost containment, medical review, staffing, and related functions • Oversee operational projects, system and reporting changes, vendor implementations, and go-lives • Analyze claims data to identify trends, issues, and improvement opportunities • Prepare and present operational and performance reports to senior leadership • Maintain knowledge of healthcare regulations, insurance and cost-sharing rules, and industry best practices • Own operational compliance, including scope-of-practice questions for clinical review staff • Maintain high-quality client service and resolve operational client issues • Ensure compliance with federal and state regulations, including ERISA, COBRA, and HIPAA • Partner with Compliance, Benefits Administration, Client Services, and other stakeholders on audits, complex claims issues, regulatory changes, and operational excellence • Occasional travel may be required

🎯 Requirements

• Proven operational leadership of a TPA or medical claims operation under client SLAs • Judgment to make director-level decisions on escalations and staffing • Ability to lead Managers, Team Leads, and Coordinators, develop staff, and manage performance • Vendor management experience, including enforcing performance standards and resolving disputes • Excellent verbal, written, and interpersonal communication skills • Exceptional analytical and problem-solving skills using SLA and aging data • Strong time management across concurrent operations, projects, and staffing work • Self-starter comfortable with broad accountability in a growing claims operation • Ability to adapt to change and adjust priorities • Proficiency with Google Suite, including expert-level Documents and Sheets, Gmail, and Calendar • Comfort operating in Salesforce as the system of record • Bachelor's degree in Business Administration, Healthcare Management, or a related field, or equivalent experience • Minimum 7 years of experience in medical claims management • At least 3 years of leadership experience in a TPA or health insurance environment • Demonstrated ability to lead and motivate a claims team, manage vendors, and own hiring and staffing for a multi-team operation • Deep operational knowledge of third-party medical claims administration and the full claims lifecycle • Command of clean-claim/clean-receipt processing-clock rules • Command of medical terminology, ICD-10 and CPT codes, and claims adjudication logic • Familiarity with clearinghouse, cost containment, repricing, medical review, claims management software, and vendor integrations • Working understanding of self-funded employer plan administration • Working proficiency in Salesforce and Google Suite • Familiarity with HCSM Needs adjudication is helpful but can be learned in role • Experience with Health Care Sharing Ministries or Medical Cost-Sharing programs is a plus, not required

🏖️ Benefits

• Competitive salary and benefits package • Opportunities for professional growth and development • Remote work flexibility • Dynamic and innovative work environment • Reasonable accommodation for qualified individuals with disabilities in the employment application process